Provider Demographics
NPI:1427038280
Name:JACKERSON, JEFFREY I (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:I
Last Name:JACKERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 W PARK PL STE 1100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-3636
Mailing Address - Country:US
Mailing Address - Phone:414-359-5745
Mailing Address - Fax:414-359-5703
Practice Address - Street 1:640 S STATE STREET
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3530
Practice Address - Country:US
Practice Address - Phone:302-674-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC200041192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000601403Medicaid
DE717195Medicare PIN
DE30049352Medicare PIN